Changing the Culture of Nursing Homes: An Idea Whose Time Has Come

1. Changing the Culture of Nursing Homes: An Idea Whose Time Has Come Long Term Care Community Coalition (LTCCC) Richard J. Mollot, Executive Director March 2008 All materials and resources are available for free at www.nursinghome411.org. This project was funded by the NY State Office for the Aging, Michael Burgess, Director.

2. Nursing Homes Now: The Good and the Bad

3. What Good Things Do Nursing Homes Do? • Provide care and residence for people who can no longer live safely on their own. • Place where people can have social activities and contacts – avoid isolation. • What can you think ofthat isgood about nursinghomes…?

4. What’s Bad About Traditional Nursing Homes? • Unpleasant, institutional setting. • Many residents receive poor care, including neglect and abuse. • Whatcan you thinkof that is bad about nursing homes…?

5. What is the Culture Change Movement? The culture change movement aims to de-institutionalize the environment of nursing homes. It involves the transformation of nursing homes from the traditional model to a more resident-centered model.

6. What does the traditional nursing home look like? – Organizational Structure • Hierarchical • Authority and Control are “top down” starting with the owners & administrators down to senior staff down to workers down to residents (and, often, their family members)

7. What does the traditional nursing home look like? – Physical Structure • Hospital ward like setting • Central area with nursing station, dining and activity areas • Resident rooms branch off in long corridors away from central area

8. What does the traditional nursing home look like? – Social Interaction • Long rows of residents in wheel chairs lining the halls • No consistent personal care staff • Little interaction between residents • Little interaction between residents and staff

9. We don’t have to – and should not – accept the status quo. • The Federal Nursing Home Reform Law (OBRA ‘87) celebrated its 20th anniversary last year. • OBRA ’87 was a landmark law that came about as a response to the terrible scandals in nursing homes in the 1970s and 1980s and attempts by the Reagan administration to decrease nursing home oversight and enforcement of protections. • It requires that nursing homes must ensure that residents receive quality of care sufficient to help them achieve or maintain their "highest practicable" physical, mental, and psychosocial well-being.

10. OBRA ’87: Resident Rights Provisions • Each resident’s ability to walk, bathe, and perform other activities of daily living will be maintained or improved absent medical reasons; • A resident assessment process is used, which leads to development of an individualized care plan; • The resident has the right to remain in the nursing home absent non-payment, dangerous behaviors, or significant changes in a resident’s medical condition; • New opportunities for potential and current residents with mental retardation or mental illnesses for services inside and outside a nursing home;

11. OBRA ’87: Resident Rights Provisions • A right to safely maintain or bank personal funds with the nursing home; • Rights to return to the nursing home after a hospital stay or an overnight visit with family and friends; • The right to choose a personal physician and to access medical records; • The right to organize and participate in a resident or family council; • The right to be free of unnecessary and inappropriate physical and chemical restraints.

12. Where Does “Culture Change” Come In? • Culture change represents change and innovation, a different way of looking at nursing home care (from what we have come to expect when we go to a nursing home). • BUT in many ways culture change is the realization of the mandate of OBRA 87. • This means that we have a right to expect – and demand – the benefits of culture change now.

13. What does a culture change nursing home look like? – Physical Structure • Resident rooms are clustered in “pods” with lounge and dining areas and decentralized nursing.

14. What does a culture change nursing home look like? – Organizational Structure • Resident is top priority, with direction and control emanating from him or her. • Others come together and interact to best serve resident and those most important to caregiving and quality of life: nurse aides and family members.

15. What does a culture change nursing home look like? • Rooms are laid out in more community-like way. • Worker stations and social areas are de-centralized. • Residents are full participants in the community. • Homes are truly home-like.

16. Almost HomeA Film About Culture Change in Real Life • The story of St. John’s Nursing Home in Milwaukee: a traditional nursing home that is now instituting culture change. • Residents, their family members, direct care workers and administrators come together to create a nursing home that is a true community. • But, like any community, there are difficulties and challenges.

17. Almost Home: Group Discussion • What are the achievements here (verses what you expect a nursing home to be like)?

18. Almost Home: Group Discussion • What challenges did you notice to achieving culture change?

19. Beyond the Movie: Making Culture Change a Reality in Our Lives • There are several ways in which people and groups across the country are making culture change a reality in their communities. • At its core, each method focuses on respecting the resident, providing individualized care and a living environment that is truly a home.

20. The Green House Project • The vision of William H. Thomas, M.D., a Harvard-educated geriatrician from upstate New York. • A Green House is a self-contained dwelling for seven to 10 people that is designed to look like a private home. • Each resident has a private room and private bathroom. • Each residence has a central hearth with open kitchen and dining areas, short hallways and a common living room area.

21. The Green House Project • Residents can share meals together and with their families and caregiver staff. • A separate caregiving “team” (including nurses, social workers, nutritionists, etc…) supports residents in multiple houses, with one nurse specifically assigned to two homes. • There is no set routine in terms of medical care or institutional organization, except as determined by the community and needs of its residents, just as in a typical home.

22. Other Models of Culture Change • Culture change can take varied shapes and forms in response to the community it serves. • Some are very small, like the Green House Project. • Some are larger, like the home in the film, that have been refitted. • Other names: Eden Alternative, Pioneer Network & Wellspring Institute.

23. KEEP 1. 2. 3. CHANGE 1. 2. 3. Exercise 1: Moving on From Traditional Nursing Homes

24. POSITIVES 1. 2. 3. NEGATIVES 1. 2. 3. Exercise 2: Moving toward a Culture Change Nursing Home

25. What can we do to make the positives of culture change a reality in our communities? • Form a state coalition to advocate specifically for culture change? • Educate people in our communities through family councils; church, temple or mosque committees; senior centers?

26. Resources Go to www.nursinghome411.org for: • more information on culture change movements, like the Greenhouse Project, that are making a real difference in the lives of nursing home residents in communities across the country; • resources you can use to learn more and educate people in your community about the benefits of culture change, financial options, etc… to build support for culture change; • copies of today’s presentation and other materials.